Among women in the United States who no longer have an abortion clinic nearby, many are turning to abortion pills ordered online, outside the U.S. medical system. As a result, the illicit abortions that were once invisible — the back-alley abortions before Roe v. Wade — are becoming increasingly possible to track and count in post-Roe America.
Counting these abortions is important to understanding the full impact of abortion bans. That means knowing how many women in states with bans are finding abortions another way, as well as how many are carrying unwanted pregnancies to term.
But researchers are debating how well the existing data captures the full scope of the post-Roe landscape. Abortion pills from overseas are a black market with limited transparency, operating outside the U.S. medical and legal systems. Although one of the biggest sources of abortion pills from overseas is sharing information about its orders, it’s unclear exactly how many women end up using such pills to end pregnancies.
Even the decrease in legal abortions as a result of Dobbs v. Jackson is hard to fully measure. In the first real-time count of abortions in the country, a research group called WeCount has been surveying most abortion clinics in the United States. It found that the number of legal abortions in July and August decreased by around 10,000 per month, a decline of 6 percent. Because only around 80 percent of abortion providers shared their numbers with the group, its researchers estimated the number of abortions for the other 20 percent.
Another group, the Self-Managed Abortion Needs Assessment Project at the University of Texas at Austin, has tried to count how many people have been requesting pills outside the U.S. medical system. Abortion pills — mifepristone and misoprostol, which together cause a miscarriage early in pregnancy — are legal in many states. There, women can get them from a doctor. In states where they are illegal to use for abortions, some women order them from overseas. The largest service doing so is Aid Access, which connects women in the United States with doctors in Europe and mail-order pharmacies in India.
The research group found that in July and August, roughly 3,000 more pills were requested each month from Aid Access, more than double the typical rate before the fall of Roe, according to research published in JAMA by Abigail Aiken, who runs the Texas project, and her colleagues.
This number is not the same as actual abortions, however. In Professor Aiken’s data, a request means that a patient completed an initial form and had at least one email conversation with Aid Access staff. It does not mean the person necessarily filled a prescription or took the pills. Some women may have changed their minds before completing their orders, found a different abortion provider or been too far in their pregnancies to be eligible for pills.
The researchers do not currently publish the number of prescriptions filled, given that the service operates in a legal gray area. Though it is illegal for a doctor not licensed in the United States to prescribe medicine to someone in the United States, enforcement is outside the jurisdiction of state law enforcement agencies. In some cases, though, people have been arrested under other laws, like those addressing child abuse or practicing medicine without a license, according to If/When/How, a legal group that supports reproductive rights. More recently, some states have been cracking down on pills as part of new abortion restrictions.
“Counting the exact number is fraught because of potential legal risk,” Professor Aiken said.
At one point, when Roe was still law, she found that 60 percent of initial requests to Aid Access resulted in pills that were mailed. In another analysis, published in The Lancet and based on follow-up interviews with people who ordered from Aid Access, she found that 88 percent of women who received pills took them. But the share may be higher now, she said, because women have fewer options.
Or it could be lower, because women in states with bans may be pursuing numerous options simultaneously, said Caitlin Myers, a professor of economics at Middlebury College who studies abortion: “It’s really hard to know how much people seeking abortions are trying to get access to every possible option in a mad scramble.”
And some women are probably getting abortions in other ways that are not included in researchers’ counts, like ordering directly from Indian pharmacies online, crossing the border to Mexico to buy pills, taking herbs, or injuring themselves.
More information about what women are doing and who is most affected by bans will be available soon. For example, Lauren Ralph, an associate professor of obstetrics and gynecology at the University of California, San Francisco, is planning a large survey of women next year that asks about all types of abortions outside the medical system.
For now, data about pills from abroad “gives us information that there’s tremendous need for abortion in these places, and people willing to use these services,” said Dr. Daniel Grossman, director of Advancing New Standards in Reproductive Health at the University of California, San Francisco. “But the magnitude, we don’t know that yet. It will take time before we understand the full impact of these bans and restrictions.”
Until recently, there had been no systematic attempt to count self-managed abortions. Professor Myers and colleagues estimated the effect of abortion restrictions enacted in 2009 in Texas by measuring births years later. They found some evidence suggesting that women close to the Mexican border might have gotten abortion pills from abroad.
Previous surveys found that even when Roe was law, small shares of women took pills or herbs to try to induce an abortion on their own. And an examination of the declining abortion rate from 2014 to 2017, compared with increased use of contraception, suggested that, in recent years, the legal abortion statistics might have missed a substantial number of American women who were ending their pregnancies with pills obtained outside the country.
Even without an exact number, it’s clear that a growing number of pills from abroad are offsetting the reduction in legal abortions. A more complete picture will be known in nearly a year, when states begin to release data on the number of births since abortion bans went into effect.
